Please Select the Type of Review Youbelieve Your Research Requires: Click Here

Study Title:

Please select the type of review youbelieve your research requires: Click here

Has or will another IRB review this protocol? Click here

Section 1: Investigator Information and Sponsor Information:

Principle Investigator:

Title:

Institutional Affiliation:

Contact Information:

Students and individuals who are not employed full-time by PBSC must procure a sponsor. The sponsor must be employed full-time at PBSC and must be agreeable and qualified to oversee the research process. ☐This section is not applicable

Sponsor:

Title:

Department:

Contact Information:

Section 2: Study Summary and Procedures:

Date you plan to begin collecting data: Click here to enter a date.

Anticipated end date of the study: Click here to enter a date.

Brief study overview, background, and purpose: (300 words max.)

Detail the study procedures including: recruitment; consent; intervention (if any); duration of contact with participants; list of data collection instruments; analysis overview; and storage, protection, and ultimate disposal of data(750 words max.):

Section 3: Participants:

Sample Size:

Concisely explain the inclusion and exclusion criteria for your sample:

Race/Ethnicity:

☐Asian ☐Black☐Hispanic ☐Native American ☐White

☐Mixed Race/Ethnicities

☐All Races/Ethnicities or not collecting information on Race/Ethnicity

Gender:

☐Female☐Male☐Transgender

☐All genders or not collecting information on gender

Age:

☐Under 18 years of age☐18 years of age or older

Vulnerable populations:

☐Not applicable

☐Minors ☐Pregnant women ☐Individuals with disabilities

☐Homeless persons☐Prisoners or those on probation or parole

☐Other (please specify)

Section 4: Risks and Benefits:

Please describe the risks associated with participation in the study:(150 words max.)

Please succinctly explain this potential, realistic, personal and societal benefits of the research(150 words max.):

Section 5: Attachments:

Please identify any documents you have submitted with your application below:

☐NIH Protecting Human Research Participants Certificate of Completion

☐Consent/Assent Forms ☐Data Collection Instruments

☐Recruitment Materials☐Copy of other IRB approval letters

☐Other (Please specify):

Section 6: Certification:

☐By clicking this box, I certify that the information provided is a complete and accurate description of the research protocol. Should changes need to be made to the protocol, I understand that I am required to submit an amendment and it must be approved by the IRB prior to implementation. I further agree to conduct my research in compliance with all applicable federal and ethical guidelines.

PI Name: Date: Click here to enter a date.

Co-PI Name: Date: Click here to enter a date.

IRB PROTOCOL APPLICATION OCTOBER 20151